Learn about getting a comprehensive orofacial pain evaluation and become an educated patient.
An orofacial pain evaluation should consist of the following steps:
The most important step in the diagnostic process is history taking, which leads the clinician to develop an initial differential diagnosis. By talking to the patient and collecting the right information, the provider narrows down the list of all the possible conditions to a few more likely ones. For example, knowing the patient’s age and gender already provides a good pointer towards conditions that may be more or less frequent in that group.
Signs and symptoms teach us about the underlying condition and its nature. When preparing for a medical appointment, be ready to answer many questions about the characteristics of the pain and the context in which it presents. Your answers probably hold the most valuable diagnostic information. A clinician is not only interested in what you are saying, but also how you are saying it. For patients seeking care for pain, the pain itself will be called the chief complaint and the details of its history are often referred to by providers as history of present illness, including:
After the history taking, the clinician should have generated a mental list of the possible conditions that could be going on. The physical examination will serve to confirm or refute such hypotheses and guide the process of diagnosis. The trained professional may be able to gather further information beyond what is volunteered by the patient, starting from general appearance, affect, posture, gait, speech, and non-verbal communication.
One of the major goals of the physical exam is to duplicate the chief complaint, as to better understand its origin and response to stimuli. For instance, dental pain is expected to be elicited or changed in a predictable manner by application of cold to the surface of the tooth; therefore a dentist uses a cold test and interprets the response to be normal or altered. To further illustrate this concept, in order to render the diagnosis of temporomandibular disorders (TMD), there should be a positive finding of pain or tenderness or range of motion of the involved muscles and/or temporomandibular joints (TMJ) on exam.
Since pain is a very personal and subjective experience, even during the exam, part of the findings will be subjective and dependent on the patient’s reports. If pain is provoked, it is crucial to discuss how the provoked pain is the same or different than what is typically experienced. The exam maneuvers may provoke pain; however, the clinician will be particularly interested in the facial pain you typically experience.
A head and neck exam should include visual inspection and palpation of masticatory and cervical muscles, TMJs, face, thyroid gland lymph nodes, teeth, mouth, and oropharyngeal mucosa. Changes in symmetry, shape, size, consistency, color, and texture should be noted. Range of motion of the head and neck should be evaluated for limitations and coordination, as well as associated pain or noises.
Cranial nerve screening evaluation is also valuable to evaluate motor and sensory functions of the major nerves supplying the face and neck. The teeth and supporting tissues should also be inspected for signs of disease, attrition, fractures, and occlusion.
No tests or exams are able to objectively confirm the source or even the presence of pain. In most cases, comprehensive history and examination will reach a diagnosis; however, there are clinical findings that require further investigation of the causes of specific signs or symptoms, especially to rule out disease or pathology underlying these features. For instance, neuralgia-type pains or neurologic deficits require brain imaging to rule out intracranial processes that could be causing the symptoms.
In a few conditions, diagnostic imaging can be used to confirm a clinical diagnosis, but in order to avoid unnecessary costs, exposure to procedure risks, and delay of therapy, it should only be ordered if the results will determine treatment recommendations. For example, in a typical case of TMD, the prognosis with conservative treatment is usually very good, and the clinical evaluation can assess with a reasonable degree of confidence that the condition is present. With computer tomography (CT), the diagnosis could be confirmed and graded in severity. The initial treatment strategy would be the same as if no imaging was done, but the patient would have been exposed to a dose of ionizing radiation and there would be associated costs to the healthcare system.
It is also important to keep in mind that no test is perfect and a certain degree of false positives (test indicates disease being present when it is not there) and/or false negatives (test indicates disease not present when it is there) is expected. The practical conclusion is that tests ordered without indication can generate misleading and meaningless results. Treatment based on the imaging findings alone is not adequate.
The response to treatment is also sometimes diagnostic. Based on the disease mechanism, there are specific drugs that seem to work so well that a significant response tells much about what is going on. It is the case of carbamazepine for trigeminal neuralgia. The rates of improvement in those cases are so high that it makes a diagnosis very unlikely if there is no significant response to the medication.
Another type of test that would have diagnostic and potential therapeutic benefit is nerve blocks, which help to locate the source of the pain and may provide relief as well. In the future, other tests may be developed to diagnose pain conditions.
Once all the information is collected, your doctor will develop a list of diagnoses that are the most likely reasons for your pain. Oftentimes there is a single diagnosis, one that fits the information that you are presenting. Sometimes the information is not clear, or the doctor is unsure, so a list of possible diagnoses or a general diagnostic category is given. This list or general category is reviewed and revised accordingly as your doctor obtains more information about you over time as your symptoms change and how you respond to initial treatments.
While the goal is to obtain the correct diagnosis right away, it can be a process occurring over a couple visits for more rare conditions. Arriving at an accurate diagnosis is a very important step to getting appropriate treatment.
Dr. Derek Steinbacher, Director of Craniofacial Surgery, Yale Medicine, Chief of Oral Maxillofacial Surgery and Dentistry, FPA Medical Advisory Board member, reviews migraines, TMJ disorders, and dental pain.
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Wolfgang Liedtke, M.D. Ph.D. is Chair of Neurology, Global Development Scientific Council at Regeneron Pharmaceuticals. Prior to that, he was Professor in the Departments of Neurology, Anesthesiology and Neurobiology; Attending Physician, Duke Neurology Clinics and Clinics for Innovative Pain Therapy, serving patients there for over 17 years.
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Dr. Larry Arbeitman will answer: What is Upper Cervical Chiropractic? How does is differ from traditional Chiropractic methods? Learn about the connection between the Upper Cervical Spine and Facial Pain, research and case studies, what you can expect from UCC and how you can integrate it into your healthcare plan. You will also be able to ask Dr. Arbeitman your questions during this live presentation.
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Dr. Jeffrey Brown, Chairman of the Facial Pain Association’s Medical Advisory Board, interviews Dr. Hossein Ansari on medical causes of neuropathic facial pain.
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Dr. Julie Pilitsis, Chair of the Department of Neuroscience & Experimental Therapeutics Professor of Neurosurgery Neuroscience and Experimental Therapeutics, Albany Medical Center and FPA Medical Advisory Board member presents an overview of trigeminal neuralgia and other neuropathic facial pains.
Dr. Konstantin Slavin discusses neuromodulation, a procedure used to treat and enhance quality of life in individuals who suffer severe chronic illness due to persistent pain.
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